Red State Blues

The Affordable Care Act, although complex, had a simple premise. If everyone is engaged in our very expensive healthcare system, then we all are motivated to improve the care. Medicaid was to be the floor but a funny thing happened on the way to health care nirvana. To quote an article in Health Affairs:

The original dream of a seamless, streamlined, no-wrong-door Medicaid, CHIP, advance premium tax credit, and cost-sharing reduction payment application and eligibility determination process has become a much more difficult reach with the Supreme Court’s still shocking interpretation of the Constitution’s spending clause, permitting the states to decline participation in the Medicaid expansion.

So, we are now into the implementation and we have 25 states who are convinced, if they just hold their collective breath long enough, something really good will happen. People in these states are being told, after they apply, “You are too poor to qualify for health insurance.” I guess we’ll teach those poor people a lesson.

The Atlantic decided to show the other side of the policy fight in an article published earlier this week. You know the side, the one where poor people get sick and die from lack of access to health care. In this article they follow several people who happen to live in Texas, make less than 138% of poverty, and thus are not granted front door access into the “greatest healthcare system in the world.” If we were playing Jeopardy (and who doesn’t love Jeopardy) and the answer was, “This large state has refused to expand Medicaid, a program that would give 1,000,000 citizens access into the health care system that they currently are denied,” you might say, “What is Texas?” and you would be correct. Then you might say, “One million, Alex? Really?”

This lack of coverage will lead to people who choose not to seek care or are denied needed care. Most of these people will merely suffer excessively. Some will die prematurely. Across America, it will be 27,000 deaths. Over 60 percent of these deaths will occur in either blacks or Latinos, the result of denying access to what almost every other country considers a basic right. Texas researchers estimate that 9,000 folks will die prematurely in Texas. The faces of these people shown in the Atlantic article include Claudia (who almost dies of a surgical misadventure) and Mark (who is dying from throat cancer, in part because no physician will provide the appropriate care).

The John Davidson of Texas Public Policy Foundation has some ideas about how to handle this situation. He thinks we need to focus on access and not insurance, and that well-meaning citizens can provide such access. For example, he cited the CareLink program run by the University Health System in Bexar County, which provides payment plans and sliding-scale rates for families who make less than 300 percent of the federal poverty level. Couple of things about that; It only serves one county, and while it provides for a “sliding fee” of payment, the amount of the bill (at cash rates, not negotiated lower insurance rates) is not adjusted. So the poor are not required to accept demeaning charity; instead, if they are lucky enough to live in Bexar County, they are required to pay an outrageous bill over time, no matter how long that takes. Turns out that 143 counties have a similar programs. Unfortunately Texas has 254 counties.

The Texas Public Policy Institute has a policy paper full of good ideas for how red states can provide care for our unfortunate too-poor citizens. Mostly, their big idea is that doctors will likely volunteer to see those one million people free of charge. I can see how that might seem appealing.

So, the next time “repeal and replace” comes up, I think the “red state doctors see poor people for free (or at least on a sliding scale)” ought to be explicitly part of the legislation. It might not be “seamless and streamlined” but it will at least make the Medical Society meetings more interesting.

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In the 1960s, people in Waco Texas began to work toward health access by design. Numerous citizens, often lower income or African American, faced gaps in coverage and care.

Unlike the current effort that focuses on coverage while ignoring the workforce to deliver the care, the Waco plan was about coverage, funding, and workforce. In the next year or two, you will see just how little will be gained because the primary care delivery currently as in past decades is still about cost cutting rather than supporting the workforce to deliver primary care.

McLennan County, the City of Waco, and the McLennan County Medical Society representatives worked with community people and groups. They decided upon a family medicine residency as a key component of their design – a design that integrated all together with existing hospitals and providers.

Sliding scale health care and sliding scale prescription access was set up. Sites for women’s health, public health, acute care, and primary care were set up. By 1970 the effort was focused on the family medicine residency, initially at 1 site but expanded across the county with pharmacists, social workers, nurse practitioners, physician assistants, nurses, faculty, and specialists involved.

Up until the 1980s, numerous specialty clinics were held where family medicine residents presented their patients at their clinic to the specialists and learned first hand about referrals, specialty services, and what primary care physicians can do or not.

By 1982 the residency had a health information system that would take most academic centers another 15 years to not quite reach. You can do that if you focus on health information to help deliver care rather than health information predominantly about billing.

Tim Henderson did a study (Tim worked for OTA and the National Council of State Legislators) and demonstrated health care costs in McLennan County one-third to one-half the level compared to similar counties. Collaborations between governments, physicians, and the community can be powerful for access, cost, and quality – but then there was the cost cutting to mess up a good thing.

State of Texas contributions remained minimal and got worse. Managed Medicaid was poorly implemented in Texas and this undermined much of the work in Waco by the city, county, medical society, residency, foundation, and others. Like a number of family medicine residency programs facing the need to provide health access but failing revenue sources, they turned to FQHC and were able to keep going, eventually expanding to 11 sites. (studies demonstrate declining funding for FM departments and programs but some advantage for funding via FQHC).

The State of Texas also cut funding for the Waco Faculty Development fellowship that has consistently improved FM faculty efforts across Waco and other states. My ETSU Minifellowship in Family Medicine design that provided substantial health access training and information dissemination was modeled after this fine program. Maurice Hitchcock, Chris Ramsey, Bill Mygdal, Steve Crawford, and many others have contributed to health access for our nation branching out from Waco. (probably about 140 fellows trained)

It would be nice to have a state that understood that instate family medicine training was by far the most important solution for instate workforce, primary care, and primary care where needed.

Sadly the state has avoided such areas. Despite the opposition/neglect, family physicians in Texas continue their important work.

One of the problems is that states actually get a limited amount of result from medical schools. Better designs for instate result are available.

One day a school will establish pure family medicine medical school training. This will require 9 years of preparation and training specific to FM with candidates arising from communities in need of health access and graduates specific to the health access needs of the community.

Estimates can already be made for a pure family medicine design. The result is 75% instate primary care result over a career and 20% of all graduates will be found instate where most needed in one of over 220 counties with less than 150 physicians per 100,000. The 75% and 20% outcomes are based upon data indicating the results of physicians born in Texas, attending instate medical schools and attending instate FM residency programs.

The continuous linkage across preparation, medical school and residency in the same design should actually decrease the number of graduates needed – as seen in the nation’s accelerated FM programs which linked instate medical school to instate FM residency (data from 1990s accel grads)

A design for 270 – 340 graduates a year specific to state needs will yield the same instate primary care and primary care where needed as the soon to be 1500 medical school graduates

About 1700 NP or PA graduates a year would be required to produce the same primary care as 340 family medicine residency graduates a year and the primary care where needed would be limited because less than 25% would be found in family practice positions – the only real multiplier of primary care where needed for MD, DO, NP, or PA.

Of course it would take states and schools and health care leaders that understand health access and the important contributions of family medicine – something in short supply.